Verbal orders drug therapy and prescription in a UK ICU setting

Abstract

Introduction: Verbal orders (VOs) drug therapy refers to drug administration without prescription, usually in the context of telephone instructions from a physician at a remote location or other circumstances involving delayed prescription. In some medical care settings VOs may constitute 2 to 13% of medication orders [1]. Prescription errors associated with VOs are reputedly common [2], although some studies suggest otherwise [3]. Although prescription errors are not uncommon in critical care [4], little is known about VOs in this setting. Methods: We prospectively audited VOs in a hardcopy-prescribing five-bed ICU setting over a period of 3 weeks, with voluntary data entry by any member of staff issuing or receiving a drug therapy VO. We collected information regarding VO timing, medication involved, clinical indication, and subsequent drug event prescription. Results: Nine VOs were recorded during multiple drug interventions for 19 ICU patients in this period, with a VO event rate of 1 for every 10 ITU bed-days. All VOs were for intravenous prescription only medication, five of which were for fluid therapy to treat acute physiological deterioration. Other drugs included metoclopramide, furosemide, atracurium, and adrenaline. No VOs for opiates were recorded. Reasons for initial nonprescription included remote location, aseptic procedure, and emergency treatment. Eight prescriptions were completed within 2 hours. No VOs were recorded during overnight shifts. All grades of medical staff issued VOs. One transcription error was noted. No adverse events were noted. Conclusions: Critical care VOs are not uncommon. Minimisation can be achieved by good communication, hardcopy or electronic bundle prescribing, locally agreed independent nonphysician prescribing arrangements, or drug administration in specific settings, particularly pre-prescription of fluid bolus therapy.